Incident Report

Subform I: General Information

1. Report Type.

New incident report

Incident Report Number: 2014-0347

2. Registrant Information.

Registrant Reference Number: 1-35721145

Registrant Name (Full Legal Name no abbreviations): WELLMARK INTERNATIONAL

Address: 100 STONE ROAD WEST, SUITE 111

City: GUELPH

Prov / State: ON

Country: CANADA

Postal Code: N1G 5L3

3. Select the appropriate subform(s) for the incident.

Human

4. Date registrant was first informed of the incident.

10-DEC-13

5. Location of incident.

Country: UNITED STATES

Prov / State: IOWA

6. Date incident was first observed.

Unknown

Product Description

7. a) Provide the active ingredient and, if available, the registration number and product name (include all tank mixes). If the product is not registered provide a submission number.

Active(s)

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PMRA Registration No.       PMRA Submission No.       EPA Registration No. 2724-274

Product Name: Starbar Golden Malrin Fly Bait

• Active Ingredient(s)
  • (Z)-9-TRICOSENE
    • Guarantee/concentration .049 %
  • METHOMYL
    • Guarantee/concentration 1 %

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7. b) Type of formulation.

Granular

Application Information

8. Product was applied?

Yes

9. Application Rate.

Unknown

10. Site pesticide was applied to (select all that apply).

Site: Unknown / Inconnu

11. Provide any additional information regarding application (how it was applied, amount applied, the size of the area treated etc).

Caller used product 3 times between July and October 2013.

To be determined by Registrant

12. In your opinion, was the product used according to the label instructions?

Unknown

Subform II: Human Incident Report (A separate form for each person affected)

1. Source of Report.

Data Subject

2. Demographic information of data subject

Sex: Female

Age: Unknown / Inconnu

3. List all symptoms, using the selections below.

System

• General
  • Symptom - Sweating

• Gastrointestinal System
  • Symptom - Vomiting

• Blood
  • Symptom - Other
  • Specify - blood cell count abnormal

• Liver
  • Symptom - Enlargement of the liver

• Blood
  • Symptom -
  • Specify - enlarged spleen
  • Symptom -
  • Specify - Electrolyte abnormal

• General
  • Symptom - Flu-like symptoms

4. How long did the symptoms last?

Unknown / Inconnu

5. Was medical treatment provided? Provide details in question 13.

Yes

6. a) Was the person hospitalized?

Unknown

6. b) For how long?

7. Exposure scenario

Unknown

8. How did exposure occur? (Select all that apply)

Application

9. If the exposure occured during application or re-entry, what protective clothing was worn? (select all that apply)

Unknown

10. Route(s) of exposure.

Unknown

11. What was the length of exposure?

Unknown / Inconnu

12. Time between exposure and onset of symptoms.

Unknown / Inconnu

13. Provide any additional details about the incident (eg. description of the frequency and severity of the symptoms, type of medical treatment, results from medical tests, outcome of the incident, amount of pesticide exposed to, etc.)

Caller started using the product in July 2013, used it 3 times, last time used in October 2013. Approximately 2 months ago developed symptoms. Caller thought she had the flu, her MD thought it was pneumonia and treated as such. Caller also received a potassium supplementation because potassium was low. Has developed more symptoms, but is not sure if related to exposure to product.

To be determined by Registrant

14. Severity classification.

Major

15. Provide supplemental information here.

Symptoms inconsistent with exposure to product.